Haryana

Yamunanagar

CC/302/2013

Anil Kuamr S/o Ramesh Kumar - Complainant(s)

Versus

OIC Ltd. - Opp.Party(s)

D.S.Khurana

29 Aug 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR

 

                                                                             Complaint No. 302of  2013.

                                                                             Date of institution: 8.4.2013.

                                                                             Date of decision: 29.08.2017.

 

 

Anil Kumar son of Shri Ramesh Kumar aged 40, resident of House No. 70, Sector 17, HUDA, Jagadhri, Tehsil Jagadhri, District Yamuna Nagar.

                                                                                                                                                                                                                                                                                                                                  …Complainant.

                                   Versus 

1. The Oriental Insurance Co. Ltd. through its Branch Manager, Old Court Road, Jagadhri, Tehsil Jagadhri, District Yamuna Nagar.

 

2. Vipul Medicorp TPA Pvt. Ltda. 515 Udyog Vihar, Phase V, Gurgaon.

 

      

 ….Respondents.

                       

BEFORE        SH. SATPAL, PRESIDENT

                        SH. S.C.SHARMA, MEMBER.

                        SMT. VEENA RANI SHEOKAND, MEMBER.   

 

Present:           Sh. D.S. Khurana, Advocate, counsel for complainant.   

                        Sh. Parmod Kumar Gupta, Advocate, counsel for OP No. 1.

                        OP No. 2 already ex-parte.

 

ORDER          (SATPAL PRESIDENT)

 

1.                         Complainant Anil Kumar has filed this complaint under section 12 of the Consumer Protection Act 1986 as amended up to date.(hereinafter  the respondents shall be referred as ops)

2.                     Brief facts of the complaint, as alleged by the complainant, are that the complainant had taken a mediclaim policy   bearing NO. 261701/48/2012/300 from OP no.1 and at the time of taking the aforesaid policy, the op no.1 had agreed to indemnify the complainant to the tune of Rs. 10 Lacs. The policy was joint of the complainant and his wife and both were insured to the tune of Rs. 5 Lacs each. The complainant fell ill as he used to suffer continuous headache and numbness in his head and ultimately the same started causing him problem in walking and due to this said reason. the complainant had to be hospitalized on 9.9..2011  in Silver Oaks  hospital where he remained admitted till 10.9.2011. The complainant immediately informed to ops no.1 regarding his admission in the hospital and submitted the requisite bills.  Thereafter again as the problem did not subside therefore again the complainant remained admitted in the hospital on 29.10.2011 till 30.10.2011 and the information regarding the same was also given to the OP no.1 . The complainant was detected with cervical spondylisis . Again, the complainant was admitted in the same hospital from 23.3.2012  to 26.3.2012 . A total sum of Rs. 97,636/- was incurred by the complainant on his treatment while being admitted in the aforesaid hospital and thereafter the complainant submitted his claim form along with requisite documents and all original bills and thereafter has followed up indemnification and has made several calls to ops no.1. at no. 01732-2641089 but neither the amount has been paid to him nor any satisfactory reply has been furnished by Op no.1 till date. A few days back a paltry sum of Rs. 24,146/- has been deposited in the account of the complainant but as a sum of Rs. 97,636/- was payable to the complainant, therefore the deposit of the said amount is un acceptable. A notice was sent by the complainant through his counsel dt. 29.10.12 but the ops   has not replied the same nor have made the payment.. Hence this complaint wherein it has been prayed that the ops   be  directed to reimburse Rs. 97,636/- alongwith interest @ 12%  PA from the date of accrual till the date of actual payment as well as to pay compensation and litigation expenses .

3.                     Upon notice, OP no. 1 appeared and filed written statement by taking some preliminary objections such as  complicated  question of law and fact is involved in this case therefore this Hon.ble Forum has no jurisdiction to hear and decide the present complaint, the complainant has not come  to this Forum with clean hands and  has concealed the true and materials  facts  and has filed false and frivolous complaint, . As per terms and conditions of the  policy at point no 4.1. when the cover incepts for the first time all excluded upto four years and the complainant insured amount was Rs. 3,00.000/- in policy no. 48/ 09 /189  w.e.f  16.6.2008 to 15.6.2009 and he intentionally and deliberately by cancelling his pre-existing  disease  got enhanced the insured amount and as such the claim is not payable and he has filed a false complaint as per exclusion clause no. 4.16 which is reproduced as under “4.16 external and or durable medical/Non medical  equipment of any  kind used for diagnosis and  or treatment including CPAP, CAPD , infusion pump etc. , ambulatory devises that is walker , crutches , belts , collets , caps , splints , slings , braces , stockings, etc. of any kind, diabetic foot wear, glucometer . thermometer and similer related items etc. and also any medical equipment which is subsequently used at home etc.” , some of  claim was not payable so the same was not rightly given  because the parties are bound by the terms and conditions of the policy . On merit, it is submitted that the complainant  took policy no. 48/09/189 w.e.f 16.6.2008 to 15.6.2009 in which the insured  value of Rs. was 3,00,000/- but he thereafter without disclosing pre-existing disease got enhanced the policy amount to Rs. 5 ,00,000/- and as per exclusion clause of the terms and conditions of the policy, no claim on enhanced amount is payable upto four years and as such to say that  op no.1 is bound  to indemnify  the complainant  to the tune of Rs. 10,00,000/- is not correct.  The complainant was required to inform the TPA within 48 hours and much before the discharge from the hospital , but the complainant has not adhered to the same . Regarding the admission in the hospital on 9.9.2011 to 10.9.2011 a claim of Rs. 35703 was raised out of which the claim payable is Rs. 24,146/- as  per terms  and conditions of the policy so the said claim stands paid and nothing more was found payable to the complainant. Regarding the alleged admission on 29.10.2011 to 30.10,2011 no claim was ever lodged by the complainant either to the TPA  or to the answering OP  and n o such claim is ever lodged and as such the same is not payable . Regarding the third admission allegedly on 23.3.2012 to 26,3,2012  the complainant has not informed either to the TPA or to the the answering OPS  wihin 48 hours as stated above : rather raised a  claim after four months of discharge from the hospital and even thereafter the TPA wrote so many letters to the complainant including letter dt. 14.9.2012, 25.9.2012 but the complainant has not completed the formalities so the claim was repudiated vide letter dt.27.12.2012 . It is further submitted that the complainant has concealed the facts that  he was having pre-existing disease and got enhanced the insured amount to put wrongful loss to the ops and wrongful gain to himself and  has not  disclosed that  he has filed complaints bearing no. 301/13, and 394/13 falsely and wrongly and as such the complaint is  not maintainable, lastly prayed for dismissal of the complaint.

4.                     OP no.2 failed to appear despite service  and as such OP no. 2 was proceeded  against ex-parte vide  order dt. 10.9.2014.

5.                     Learned counsel for the complainant has tendered into evidence by way of an affidavit of the complainant as Annexure CW/A alongwith documents as Annexure C-1 to C-19 and closed the evidence on behalf of the complainant

6.                     On the other hand learned counsel for Op no. 1 tendered into evidence affidavit of Sh. Sanjeev Madan Branch manager as Annexure RW/A and documents as Annexure R-1 to R-7  and closed the evidence on behalf of op no.1.

7.                     We have heard the learned counsel for both the parties and has gone through the pleadings as well as documents placed on file very minutely and carefully.  Learned counsel for the complainant argued that the complainant having medical claim policy for reimbursement to the tune of Rs.5,00,000/- and the said policy bearing No.0261/48/2012/300 is valid from 16.6.2011 to 15.6.2012.  The complainant fell ill  due to cervical spondylises and had admitted in Silver oak Hospital, Mohali on 9.9.2011 and discharged on 10.9.2011 and intimated the OP No.1 immediately and thereafter again the complainant remained admitted in the hospital on 29.10.2011 and discharged on 30.10.2011.  Intimation regarding the same was also given to OP No.1 but the problem did not subsides and again the complainant again admitted in the hospital on 23.3.2012 and discharged on 26.3.2012 and as such complainant spent Rs.97,636/-.  The learned counsel for the complainant further argued that the OP-Insurance company had deposited an amount of Rs.24,146/- in the account of the complainant whereas the amount of Rs.97,636/- was to be paid by the OPs and prayed for acceptance of complaint.

8.                     On the other hand the learned counsel for the OP No.1 argued that as per terms and conditions of the policy at point no.4.1, when the cover incept for the first time are excluded up to four years and then the complainant is only entitled for the sum assured of Rs.3,00,000/-.  The amount was reimbursed to the complainant vide terms and condition no.4.16, term no.1.2 (a) of the policy.  Some claim was not payable so the same was rightly not reimbursed as the parties are bound with terms and conditions of the policy.  The counsel for the Op No.1 further argued that regarding the admission in the hospital from 9.9.2011 to 10.9.2011 a claim of Rs.35,242/- was raised and out of which the claim payable is Rs.24,146/- and the same was transferred in the account of the complainant on 21.9.2012 and as terms and conditions of the policy nothing more was found payable to complainant.  It is further argued that regarding the admission on 29.10.2011 to 30.10.2011, no claim ever been lodged by the complainant as such the same is not payable and regarding the third claim admission of complainant from 23.3.2012 to 26.3.2012 the complainant has not informed either the TPA or the Insurance company within 48 hours, the said claim was raised by the complainant after four months of his discharged from the hospital.  Several letters were written to the complainant for completing formalities but the complainant failed to complete the formalities and thereafter vide letter dated 27.12.2012 the claim of the complainant was repudiated and prayed for dismissal of complaint.

9.                     After hearing the learned counsel for the parties and going through the records, it is clear that the main grievances of the complainant is that he was hospitalized three times i.e. 9.9.2011 to 10.9.2011, 29.10.2011 to 30.10.2011 and 23.3.2012 to 26.3.2012 and the OPs had paid only Rs.24146/- to the complainant whereas a sum of Rs.97,636/- was payable to him.  It is admitted by the parties that when the complainant remained admitted in the hospital for treatment, the medical claim policy was in force.  The foremost question which arises before us for consideration is whether the complainant is entitled for reimbursement of total amount of Rs.97,636/- or not?  The version of the OP No.1 is that as per annexure R.5 regarding admission from 9.9.2011 to 10.09.2011 the claim of the complainant was processed and as per terms and conditions Rs.24,146/- was paid against claimed amount of Rs.35,242/- and remaining amount of Rs.11096/- was disallowed as per terms and conditions of the policy towards non-payable items.  Regarding admission from 29.10.2011 to 30.10.2011, the version of the Op No.1 is that the complainant has not lodged any claim till today and as such the Op No.1 is not liable to pay any amount.  Regarding admission from 23.3.2012 to 26.3.2012 the version of the OP No.1 is that the complainant has lodged the claim after four months of his discharge, however, as per terms and condition no.5.4 the claimant was bound to inform the company within 48 hours of his hospitalization but the complainant has inform the OP No.1 after four months of his discharge. .

 10.                  We have gone through the terms and condition no.4.16 of the policy which is reproduced as under:-

“External and or durable medical/non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc. Ambulatory devices i.e. walker, crutches, Belts, Collars, Caps, Splints, Slings, braces, Stockings etc. of any kind.  Diabetic foot wear, Glucometer/Thermometer and similar related items etc and also any medical equipment which is subsequently used at home etc”.

As per terms and conditions 4.16 of the policy the complainant is not entitled for reimbursement of external and or durable medical/non medical equipment.  The Op company disallowed Rs.11,096/- due to non payable items i.e. medicines etc. which is clear from the Annexure R.5. 

                        We have also gone through the terms and conditions No.5.4 and 5.5 of the policy which is reproduced as under:-

NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID card No., Name of insured person in respect of whom claim is made, Nature of disease/illness/Injury and Name and address of the attending medical practitioner/ Hospital/ Nursing Home etc. should be given to the Company/TPA while taking treatment in the Hospital/Nursing Home by Fax, Email.  Such notice should be given within 48 hours of admission or before discharge from Hospital/Nursing Home, unless waived in writing.

5.5       Claim Documents: Final claim along with hospital receipted original bills/cash memos/reports, claim form and list of documents as listed below should be submitted to the company/TPA within 7 days of discharge from the Hospital/Nursing Home.

                        In the present case, it is admitted that the complainant had lodged the claim for the period from 23.3.2012 to 26.3.2012 after four months of his discharge from Silver Oak Hospital and as per terms and conditions no.5.4 and 5.5 the complainant is bound to inform the company within 48 hours and thereafter lodge the claim within 7 days with the OP-company.  So, we are of the view that the complainant himself violated the terms and conditions of the policy and as such the complainant is not entitled for any claim.

11.                  In view of the facts, discussed above, we are of the considered view that the OPs have rightly paid/reimbursed the medical claim for the treatment for the period from 9.9.2011 to 10.9.2011 as per the terms and condition of the policy.  There is no merit in the complaint of the complainant, hence, the same is hereby dismissed with no order as to costs.  Copies of this order be sent to the parties free of costs.  File be consigned to the record-room after due compliance.

 

Announced in open court.                            (SATPAL)

Dated: 29.08.2017                                          PRESIDENT

                                                                  D.C.D.R.F.YAMUNA NAGAR

                                                                  AT JAGADHRI

 

 

(VEENA RANI SHEOKAND)                    (S.C.SHARMA)

MEMBER                                                      MEMBER.